A 33 year old woman with severe multiple trauma to head, chest, liver and long bones has  been  in  your unit  for a  week  and  has  been  slowly recovering.    She  suddenly develops  acute  hypoxia  (PaO2  55 on  FiO2  of 0.8 + 10cm  PEEP)  and  hypotension (80/46) due to an acute pulmonary embolism.  Outline the key features of management, and your rationale for each.

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College Answer

The key features of management and rationale should include:
•    Resuscitation: fluids, consideration of further monitoring/investigation, vasoactive support, and evaluation/adjustment of ventilation/FIO2 to increase PaO2.
•    Full  anti-coagulation unless  strong  contraindication still  exists  (eg.  worsening cerebral haemorrhages)
•    Consideration of thrombolytics based on haemodynamics [eg. echocardiography] (probably contraindicated unless peri-mortem!).
•    Consideration of surgical removal if thrombolysis contraindicated and haemodynamically unstable, but would need to tolerate anticoagulation and cardio-pulmonary bypass.
•    Consideration of vena caval filter for prevention of further emboli (depending on source of emboli, if unable to anticoagulate etc)
•    General supportive care

Discussion

This, given the haemodynamic instability, is a case of massive pulmonary embolism.

A question like this would benefit from a systematic answer.

  • Attention to ABCs, with correction of immediately life threatening complications
  • Airway
    • intubation may be required to apply a controlled FiO2
  • Breathing
    • Increase FiO2 to correct hypoxia
  • Circulation
    • Fluid boluses to increase right heart filling
    • pulmonary vasodilator and inotrope eg. milrinone, to increase forward flow though the pulmonary circulation
    • inhaled pulmonary vasodilators, eg nitric oxide or prostacycline
  • Anticoagulation/thrombolysis
    • thrombolysis likely to be absolutely contraindicated given the history of recent trauma
    • anticoagulation may be relatively contraindicated if there are evolving intracranial haemorrhagic events
  • Rescue therapy
    • Embolectomy
    • Clot lysis / clot retrieval by interventional radiology
    • VA ECMO if anticoagulation not contraindicated and other measures fail or are not available
  • Preventative therapy
    • long term anticoagulation
    • vena cava filter

References

References

Kucher, Nils, et al. "Massive pulmonary embolism." Circulation 113.4 (2006): 577-582.

 

Kucher, Nils, and Samuel Z. Goldhaber. "Management of massive pulmonary embolism." Circulation 112.2 (2005): e28-e32.